Healthcare Provider Details

I. General information

NPI: 1073663506
Provider Name (Legal Business Name): MARY KAY HOSTETLER NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 STANTONSBURG RD
GREENVILLE NC
27834-2818
US

IV. Provider business mailing address

2223 LOCKSLEY WOODS DR UNIT #H
GREENVILLE NC
27858-5455
US

V. Phone/Fax

Practice location:
  • Phone: 252-847-4113
  • Fax: 252-847-9946
Mailing address:
  • Phone: 252-355-5720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number137721
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: